The Computerworld Honors Program
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Final Copy of Case Study
LOCATION:
Bendigo, AU

YEAR:
2009

STATUS:
Laureate

CATEGORY:
Healthcare

Technology Area:
Video conferencing solution

ORGANIZATION:
Loddon Mallee Rural Health Alliance

ORGANIZATION URL:
http://www.lmha.com.au

PROJECT NAME:
Providing critical care support to regional and rural areas of Victoria, Australia through video conferencing

Introductory Overview
The increasing use of information and telecommunications technologies, including broadband technologies, has assisted the Australian health care system to continue to strive for greater efficiency and effectiveness whilst providing high levels of quality and accessible health care.

The greatest challenges for the Australian health care sector include meeting the needs of rural communities for health care despite their distance from regional centres and associated medical facilities.  A concurrent issue is the shortage of specialist clinicians in many rural and regional centres.

The Loddon Mallee Virtual Trauma and Critical Care Unit(ViTCCU) initiative addresses the issues of distance, remoteness and shortages of specialist trauma staff in regional and rural areas. The pilot utilises the capabilities of a broadband network and recent advances in video conferencing technology and applications to provide virtual Trauma Care from Melbourne into regional Victoria.

ViTCCU enables metropolitan trauma specialists to provide virtual consultations with a clinician at an Emergency Room in the Loddon Mallee region, enabling fast responses to critical trauma events leading to a reduction in the impacts of trauma.

The ViTCCU project connects the following hospitals

* The Austin Hospital, Melbourne

* The Royal Childrens Hospital, Melbourne

* The Alfred Hospital, Melbourne

* St Vincents Hospital, Melbourne

* Bendigo Hospital,

* Echuca Hospital,

* Swan Hill Hospital,

* Mildura Hospital

The Bendigo Hospital is the primary referral site in the region for smaller hospitals; however all regional hospitals including Bendigo receive trauma and critical care advice from a number of metropolitan hospitals.

Existing practice is triage patients to identify the level of treatment required. This may involve stabilisation prior to transfer to a metropolitan hospital.  With the implementation of this project we expect that more patients will be triaged to enable more patients to be treated locally.

The goals of the project are to:

* provide virtual specialist care and advice to Bendigo, Echuca, Mildura and Swan Hill hospitals from Melbourne hospitals;

* improve the remote diagnosis of critically ill regional patients and improve the process of stabilising their condition;

* reduce the incidence of unnecessary transfer of regional patients to metropolitan facilities;

* reduce the social impact on the patients family of unnecessary transfers from the regional hospital;

* improve the skills of regional medical staff through knowledge transfer facilitated by the virtual interaction with specialist staff;

* reduce the total cost of patient care;

* formally evaluate the outcomes of the installation of the ViTCCU to determine the suitability of a wider scale deployment to other regional hospitals.

The ViTCCU project consortium include:

* Loddon Mallee Health Alliance

* Telstra

* Cerner

* KPMG

* Polycom

* IBM

This project is supported by funding from the Australian Government under the Clever Networks Program, the Telstra Foundation and Multimedia Victoria,  a department of the Victorian state government.


The Importance of Technology
How did the technology you used contribute to this project and why was it important?
The system consists of a purpose built cart at the foot of the patients bed in the emergency or intensive care ward at a rural hospital. Similar equipment is available at the emergency or intensive care ward at a metropolitan hospital in Melbourne.

The equipment consists of: 

* A Patient Cart:  located in the resuscitation bay at the regional hospital equipped with a Polycom video conferencing equipment, cameras, microphones, high resolution video monitor and facilities to interface to hospital equipment. Clinical staff can access the shared patient clinical record using a centrally hosted installation of Cerner Powerchart via a tablet PC.

* A Specialist Unit: located at the major metropolitan hospital and equipped with Polycom videoconferencing equipment, a high quality video monitor, video camera and an audio system enabling the specialist to interact with the team caring for the patient. The specialist has access to the shared clinical record using a centrally hosted installation of Cerner Powerchart and diagnostic results through a dedicated desktop PC.

* Server equipment situated in a Telstra managed data centre.

Using the infrastructure provided by ViTCCU and a dedicated 100Mbps connection, images of the patient, staff and the resuscitation area together with stereo audio, vital signs telemetry (to be implemented), patient records and diagmosic results are viewable by a traumatist in Melbourne.  The specialist uses the system to review the clinical data and images, supervise the remote care team and advise on care of the patient.  The remote specialist is seen and heard in the rural hospital at the point of care.

All video sessions are recorded centrally for the purpose of quality and clinical review.

The system requires a high availability, high bandwidth broadband network.

This project has the potential to be a demonstration project to illustrate the benefits of using broadband in regional and rural Australia.

The installation of ViTCCU units augments specialist clinical support for healthcare workers in the regional hospitals by:

* providing improved support for local doctors, principally General Practitioners (GPs), dealing with acute trauma cases,
* providing better patient information for the supervising trauma specialist,
* allow quicker decisions on the right treatment,
* produce better decisions on the need for patient transportation,



Benefits
Has your project helped those it was designed to help?  
Yes


Has your project fundamentally changed how tasks are performed?  
No


What new advantage or opportunity does your project provide to people?
Critical trauma victims must reach definitive care within a short period of time, often called the golden hour, to help prevent death or disability. The Loddon-Mallee Virtual Trauma Critial Care Unit (ViTCCU) project has the potential to imfluence the delivery of patient care to remote hospitals in regional Victoria. 

Studies have shown that coordination of the emergency medical resources in an area can result in a major decrease in preventable trauma death rates.  VicRoads, the Vitorian government roads authority, states that the cost to the Victorian economy of road trauma is more than $2.9 billion annually while the cost to the community of each trauma related death is $590,000.

Rural areas may not have the means to provide the complete continuum of care and therefore, preventable death rates due to trauma in these areas may be considerably higher than urban areas.  The problem is further compounded as many metropolitan trauma sites have limited capacity to accept rural trauma transfers because of their own patient loads.

The project provides specialist trauma expertise to these remote hospitals through a broadband network with a range of information including radiological images, pathology results, vital signs (under implementation) and high definition vision. This information assists the specialist trauma team to identify an appropriate clinical pathway for the patient involved in the trauma event. 

More specific details of these outcomes and benefits are: 

Health Sector Benefits
The ViTCCU project delivers the following health sector outcomes and benefits:

* providing real-time collaboration, including ultra high definition video, vital signs telemetry and diagnostic images between rural health practitioners and metropolitan trauma specialists will enhance the decision-making process and quality of health care for patients. Currently, when a rural doctor is confronted with a complicated  trauma event, a decision to transfer the patient to a metropolitan facility is often undertaken in the absence of appropriate trauma expertise and access to a second opinion;

* in conjunction with the trauma specialist, the rural doctor can make a more informed decision on treatment options which may include:
- immediate  transfer;
- stabilisation and transfer;
- or treatment locally with appropriate guidance;

* the local treatment option may involve less experienced clinicians being guided through more complex procedures under direction from the trauma specialist with treatment or transfer options to be considered in the ensuing period; this would also allow the Accident and  Emergency staff to maintain effective and efficient patient management with appropriate support;

* enables metropolitan specialists to access relevant critical information ahead of patient arrival should it be decided to immediately transfer the patient to the nearest trauma facility; this will also allow time to engage the relevant staff and to prepare operating theatres and other services;

* access to this experience for local medical and nursing staff will enhance the clinical knowledge of regional staff through the virtual interaction with the specialist trauma staff assisting to alleviate professional isolation; 

* improved diagnostic abilities are expected. Rural medical staff can collaborate on a timely basis with their specialist metropolitan counterparts to share and discuss treatment options.  Observation and discussion of the trends emanating from the vital signs and the relevant clinical results and radiology images will ultimately assist in saving lives and reducing levels of long-term disability in rural communities;

* obtain specialist reinforcement for the proposed treatment plan as discussed with the relevant family members and the local clinical staff to assist comprehension of the likely outcomes.

Confidential patient feedback at this stage of the evaluation phase of ViTCCU is encouraging and provides additional evidence that the project is helping those that it was designed to help.


If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
The Virtual Trauma and Critical Care Unit project will provide support for local regional doctors, in smaller towns, dealing with trauma or specialist cases, by linking them via video conferencing and broadband equipment, with trauma and critical care specialists at Melbournes Alfred, Austin, St Vincents and Royal Childrens hospitals.

The project is an expansion of an existing telephone service already provided to regional doctors by metropolitan specialists.

Alan Taylor (Chairman of the LMRHA board) highlights the benefits.

ViTCCU offers many benefits to regional patients and their families. 

In the majority of cases, critically ill patients are stabilised so they can be transported to Melbourne. With this project, more patients will be able to be treated in their local hospital, by their local doctor and remain close to their home, family and friends, reducing the stress and trauma of being transported to a metropolitan hospital.

This will also increase the knowledge of regional medical staff which will further improve patient care in regional and remote areas.  

Confidential patient feedback at this stage of the evaluation phase of ViTCCU is encouraging and provides additional evidence that the project is helping those that it was designed to help.


Originality
Is it the first, the only, the best or the most effective application of its kind?   None of the above

What are the exceptional aspects of your project?
LMHA has undertaken a review of some of the overseas programs.  These initiatives have been carefully considered with a view to gleaning additional information which might assist the Loddon-Mallee Virtual Trauma Critical Care Unit (VitCCU) project.

In Arizona, nine rural hospitals are participating in a program which is being overseen by the University Medical Centre in Tucson.  The tele-trauma program facilitates the virtual presence of a physician at the nine nominated emergency rooms.  The increased access to specialist expertise is expected to save lives, increase efficiency, and bring an improved level of health.

In Sioux City, Iowa several hospitals are using technology to allow intensive care physicians to monitor intensive care patients in another city.

From a European perspective, many of the uses of telemedicine and/or eHealth are related to distance teaching, remote foetal ultrasound, telecardiology, the use of PET scanning,(which uses an imaging technique for detection of brain disorders and tumours), a Norwegian initiative called the second opinion network, and endoscopic surgical procedures.

One Australian example of using broadband in a critical clinical situation has been the ViCCU (Virtual Critical Care Unit) project based in the Blue Mountains in New South Wales. This project sought to address the problems of shortages of Critical Care staff in regional and rural areas by developing a system that could use the capabilities of broadband networks so as to have a Critical Care Specialist virtually present at a distant location. This is not possible in a clinically useful way within the current systems. A new system (ViCCU) was developed and deployed. Critically ill or injured patients are now routinely assessed and managed remotely using this system. It has led to a more appropriate level of transfers of patients and the delivery of a quality of clinical services not previously available.

The formal evaluation of the trial has now been finished and some conclusions regarding improvements in patient care and a definitive reduction in unnecessary ambulance transfers has been identified; however, additional data compiled over an extended timeframe is required to reinforce these findings.

Unfortunately, attempts to commercialise the research were unsuccessful, principally because the technology was built as a research project and designed for the project.

Other relvant e-health projects funded by the Australian government though the Clever Networks program include: 

* Bush Medivac Western Australia project

* eHealth for Remote Australia project

* ShiresNet project  Northern Territory

* Enhancement of Telehealth in Western Australia project

* Clinical Outreach  Hunter New England project

Other relevant Australian projects include:

* E-health trial in Queensland

* Access health  fibre for greenfield projects

* SA Internet health record system


ViTCCU builds upon the successes of earlier projects and seeks to avoid the sustainability problems by:

* using commercially available technologies in a clinically focussed manner.

* including plans to amend the ViTCCU private network model to a more inclusive network design model as a project deliverable. 

* fostering the partnership with KPMG which provides a comprehensive benefits and performance measurement framework for the project. 

At the end of the funded project the benefits and business case for ViTCCU will be clear.


Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
A structured project methodology, PRINCE2, was used for the Virtual Trauma critical Care Unit (ViTCCU) project. PRINCE2 provided a method for managing the project within a clearly defined framework. Using this approach each process is specified with its key inputs and outputs and with specific goals and activities to be carried out, which gives an automatic control of any deviations from the plan.

A change control system is in place to ensure that any changes to the production ViTCCU system are implemented in a controlled manner.

Engagement with clinical staff in all of the participating hospitals has been an ongoing challenge for the project. Staff turnover has been a major factor. Engagement with Visiting Medical Officers (VMOs) in rural hospitals is an ongoing challenge. These challenges have been met, in part, through an extensive training program and the formation of a clinical working party (CWP) with representation from all participating hospitals. During the implementation phase of the project the CWP actively supported the development of processes to tailor the use of ViTCCU to meet the needs of the participating agencies. Within the evaluation phase the CWP acts a marketing / promotion tool for the project and members of this group are champions for the use of ViTCCU within their respective organisations.

General Practitioner (GP) engagement is an ongoing process as GPs in private practice form the bulk of VMOs in rural hospitals. The Project Office is liaising with Divisions of General Practice in the region to engage with GPs as required through practice visits and attendance at continuing professional development (CPD) events. Through these approaches, ViTCCU is enjoying an enhanced profile within General Practice.

The wide range of participating organisations has highlighted some differences in organisational culture which had the potential to impact on the project. For example, ViTCCU data collection is necessary to develop a business case to ensure the long-term sustainability of the inintiative. KPMG were finding barriers to the provision of some information and joint LMHA/KPMG approach was developed to overcome objections to the data collection process.
 
The ViTCCU network and infrastructure has proven to be reliable and resilient. However, technical problems with the ViTCCU equipment, however minor, always have the potential to alienate end-users and lead to avoidance of the technology. A comprehensive technical support process is in place which leverages upon the IT support processes within participating agencies. Second level support is provided by LMHA on a 24/7 basis. If necessary, ViTCCU problems can be escalated to Cerner or Telstra for resolution. An issues log is maintained by the ViTCCU project office to help identify common issues.


Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
N/A


Success
Has your project achieved or exceeded its goals?  
No


Is it fully operational?   No

How do you see your project's innovation benefiting other applications, organizations, or global communities?
A major impediment to the more widespread use of broadband in the health sector has often been identified as the provision of access to broadband at an affordable price. The perceived productivity benefits which could be derived from the health sector are thought to be significant; however, the various tiers of government continue to debate the costs of the initial broadband structure and the ongoing affordability of connectivity.

In those regions where a health broadband network exists, much of the application traffic relates to supporting backend administrative systems such as a Financial Management Information System (FMIS), Patient Information System (PMS), payroll and Human Resource Information Systems (HRMIS).  

Given the limited clinical use of broadband and advanced telecommunications technologies, this project proposes to demonstrate the potential use of ICT in a clinical setting as a national exemplar.

The Loddon Mallee Health Alliance provides a broadband network to the public hospitals in this region. The network provides a 20Mbps connection to each hospital site. In order to implement the Loddon-Mallee Virtual Trauma Critical Care Unit (ViTCCU) applications beyond the current Australian Government funded period it is likely that the dedicated ViTCCU network will be further integrated with the existing LMHA network. This will require expanded broadband capacity for LMHA member agencies.

National and community benefits from the ongoing success of ViTCCU include:

* similar projects could be considered across Australia with ultrabroadband links connecting rural and remote locations back to their metropolitan counterparts;

* cost savings from inappropriate ambulance transfers thus ensuring that the utilisation of trauma expertise is optimised whilst minimising the extent of family dislocation;

* longer term benefits to these rural and regional communities from the sustainability of their health services. People will remain or relocate to areas where health care is available and sustainable;

The social and financial costs associated with a trauma case in any rural location cannot be underestimated.  Trauma of any kind at any time will create enormous difficulties for the individuals, families, and friends of those involved. These difficulties are increased dramatically where the family members are physically distant from each other. Ther social dislocation and consequent loss of productivity is a major cost to the community.

The prime benefits for the small to medium sized enterprises in rural settings will emanate from reduced absence by members of the workforce who are involved or acting in a supporting role as a consequence of a trauma event. Family businesses would be affected and may need to close until the trauma event reaches some conclusion. If these absences are reduced through more appropriate triage processes, businesses and families will benefit. 

Travel requirements to distant locations for employees and business proprietors in support roles would also be reduced as a consequence of a reduction of unnecessary hospital transfers. 



How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
The clinical staff in participating hospitals have generally been very supportive of the Virtual Trauma Critical Care Unit (ViTCCU) project. The nursing staff and Hospital Medical Officers (HMOs) are very enthusiastic about the potential of ViTCCU to improve patient outcomes. It is this group that have had ready access to the equipment and training opportunities. 

The ViTCCU Clinical Working Party has been pivotal in maintaining interest and maximising the opportunity ViTCCU offers.

Visiting Medical Officers (VMOs), largely comprising GPs in private practice in rural areas, have been a little slower to embrace the ViTCCU at the early stage of the initative. Some of this group have not been available to participate in familiarisation or training sessions during the implementation stage of the project. Work of the ViTCCU Project Office to raise awareness of ViTCCU with all members of this group is being positively received. Targetted training and familiarisation activities are underway to raise awareness and understanding of the aims of ViTCCU.


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